Integrating Ethics Throughout the Veterans Health Administration

Imagine that you’re a nurse or a doctor in the following situations:

A recovering heroin addict complains of severe leg pain following hip surgery. He demands pain medication. How do you assess and treat the patient’s pain? Do you consider his former drug use in developing a treatment plan?

You arrive at your weekly home visit with a patient who has an aggressive dog. Dreading an encounter with the dog, you wantto stop coming to the home. However, as a health care professional, you have an obligation not to abandon a patient. What shouldyou do?

With limited resources, you have to decide whether to continue to provide mammography services to a small number of female veterans or to lengthen waiting times for other radiology services.

In health care institutions throughout the United States, ethical dilemmas like these have historically been dealt with on a case-by-case basis, often leaving health care workers overwhelmed and confused about what care protocol they should follow. To infuse a clear and consistent process for ethical decision-making, the Veterans Health Administration (VHA) will soon incorporate an “integrated ethics program” throughout its system, which is the largest health care system in the United States. The VHA is working with EDC’s Center for Applied Ethics and Professional Practice to develop training and curriculum materials for the program.

“The motivation for an integrated ethics program is first, to provide the best care for veterans, and second, to build integrated structures and processes that can proactively address ethical concerns wherever they arise in the VHA system, from the clinic to the boardroom,” explains Rebecca Jackson Stoeckle, project director. The project aims to facilitate the decision making of health care professionals throughout individual facilities, to transform the VHA’s traditional ethics committees into an integrated ethics program that is more responsive to today’s complex health care needs. “If you flood the entire institution and have a critical mass of people caring about ethical issues, you can change the way an institution works. Otherwise you’re just tweaking at the margins.”

The VHA is uniquely poised to undertake such an initiative, says Stoeckle. It holds a reputation for first-class care, and as more veterans lose access or can’t afford private insurance, they are turning to the generous benefits offered to those who served in the military. Another feature of the VHA health care system makes it an ideal place for the project, notes Stoeckle—as a government institution, the VHA system can issue directives that can be quickly implemented throughout its 174 medical centers, more than 750 outpatient, community, and outreach clinics, and 135 nursing home care units. When working with private sector institutions, such recruitment and compliance issues can be huge, explains Stoeckle.

An integrated ethics program will provide clear structures for dealing with ethical concerns for people in all areas of the VHA system, from patients to practitioners to the most senior leadership. This clear structure is formed by four program elements:

Alignment between standards and practice through an infrastructure that fosters integration between ethics activities throughout the organization

A clearly defined approach to ethical cases that arise in the clinical setting

A strategy for responding to recurring ethical cases on a systems level

Ongoing assessment to evaluate ethics quality

The goal of the integrated ethics program is to build on these four elements to continuously improve ethics quality. For example, anyone in the VHA system who has an ethical concern, such as the nurse who feels unsafe around an aggressive dog, reports the concern to a Case Consultation Team. When an ethical concern recurs across multiple cases, the Case Consultation Team identifies it as an ethical issue and refers it to an Issues Analysis Team, which initiates a system-wide action plan. An assessment team might conduct a series of telephone interviews with a sample of staff members to collect data about an ethical issue or the impact of a program policy.

The VHA project draws on EDC’s Decisions Near the End of Life project, a national education program designed to strengthen institutional policies and procedures about life-sustaining treatment and to help clinicians make informed decisions about the care of dying patients. “What ‘Decisions’ did that no other project had done was to approach bioethics at the organizational or institutional level,” says Stoeckle. “The VHA is helping to pioneer the enactment of integrated ethics in health care institutions,” Stoeckle adds. “We’re taking a new look at the organizational chart and making sure ethics appears everywhere, such as in job descriptions, communication structures, reporting mechanisms, and performance reviews. With an integrated approach, ethical decision making will be integrated into all aspects of the VHA system, rather than be a collateral duty—one more thing piled on top of what people already have to do. It’s a day-to-day issue.”

The curriculum materials for the integrated ethics program will include face-to-face workshops for clinicians, administrators, and managers from each of the 23 regional VHA networks, who will then provide training to staff in their regions. The curriculum will also include video-based skill building courses and computer-based modules that allow for self-directed learning. “It’s both a top down and a bottom up approach that involves those at the most senior leadership level as well as staff at patients’ bedsides and in the clinic,” explains Stoeckle.